Updated 14 December 2021
We carried out this announced focused inspection on 25 November 2021 under section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. We planned the inspection to check whether the registered provider was meeting the legal requirements in the Health and Social Care Act 2008 and associated regulations. The inspection was led by a Care Quality Commission, (CQC), inspector who was supported by a specialist dental adviser.
To get to the heart of patients’ experiences of care and treatment, we asked the following three questions:
• Is it safe?
• Is it effective?
• Is it well-led?
These questions form the framework for the areas we look at during the inspection.
Our findings were:
Are services safe?
We found this practice was providing safe care in accordance with the relevant regulations.
Are services effective?
We found this practice was providing effective care in accordance with the relevant regulations.
Are services well-led?
We found this practice was providing well-led care in accordance with the relevant regulations.
Background
Holloway House Dental Surgery is in Minehead and provides NHS and private dental care and treatment for adults and children.
The practice is not suitable for patients with limited mobility due to steps to access and internal steps. If patients contact the practice to discuss mobility needs the staff team can advise how they can assist or direct to a more accessible practice. Car parking spaces are available near the practice.
The dental team includes three dentists, five trainee dental nurses, one dental hygiene therapist, one patient manager and a receptionist/trainee dental nurse. The practice has four treatment rooms.
The practice is owned by an individual who is the principal dentist there. They have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the practice is run.
During the inspection we spoke with two dentists, one dental hygiene therapist, two trainee dental nurses, one trainee dental nurse/receptionist and the patient manager. We looked at practice policies and procedures and other records about how the service is managed.
The practice is open: Monday – Thursday 8.30am – 5.30pm
Friday 8.30am – 4.30pm.
Our key findings were:
- The practice appeared to be visibly clean and well-maintained.
- The provider had infection control procedures which reflected published guidance.
- Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available.
- The provider had systems to help them manage risk to patients and staff. However, the fire risk assessment needed updating and there was no system in place for checking that equipment used and provided by a visiting specialist was validated and in working order.
- The provider had safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
- The provider had staff recruitment procedures which reflected current legislation.
- The clinical staff provided patients’ care and treatment in line with current guidelines.
- Staff treated patients with dignity and respect and took care to protect their privacy and personal information.
- Staff provided preventive care and supported patients to ensure better oral health.
- The appointment system took account of patients’ needs.
- The provider had effective leadership and a culture of continuous improvement.
- Staff felt involved and supported and worked as a team.
- The provider asked staff and patients for feedback about the services they provided.
- The provider had information governance arrangements.
There were areas where the provider could make improvements. They should:
- Take action to review the practice's fire safety risk assessment and ensure ongoing fire safety management is effective.
- Improve the practice's systems for checking and monitoring equipment taking into account relevant guidance and ensure that all equipment is well maintained. In particular, equipment brought onto site by the visiting dentist.